Most Recent Deficiencies for FAIR HAVEN SHELBY COUNTY

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Updated as of November 01, 2021

A list of the most recent deficiencies for FAIR HAVEN SHELBY COUNTY. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.

Deficiency Type of Deficiency Deficiency Date Date Corrected Resulted from a Complaint?
Provide and implement an infection prevention and control program. Health 2021-01-21 2021-03-04 N
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Fire Safety 2019-11-21 2020-03-31 N
Install corridor and hallway doors that block smoke. Fire Safety 2019-11-21 2020-03-31 N
Respond appropriately to all alleged violations. Health 2020-02-10 2020-03-20 Y
Develop and implement policies and procedures to prevent abuse, neglect, and theft. Health 2019-11-21 2020-01-10 N
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2019-11-21 2020-01-10 N
Respond appropriately to all alleged violations. Health 2019-11-21 2020-01-10 N
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Health 2019-11-21 2020-01-10 N
Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. Health 2019-11-21 2020-01-10 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2019-11-21 2020-01-10 N
Provide enough food/fluids to maintain a resident's health. Health 2019-11-21 2020-01-10 N
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Health 2019-11-21 2020-01-10 N
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Health 2019-11-21 2020-01-10 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2019-11-21 2020-01-10 N
Provide and implement an infection prevention and control program. Health 2019-11-21 2020-01-10 N
Implement a program that monitors antibiotic use. Health 2019-11-21 2020-01-10 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2019-10-16 2020-01-10 Y
Have an enclosure around a vertical opening shaft. Fire Safety 2019-11-21 2020-01-10 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2019-11-21 2020-01-10 N
Have proper medical gas storage and administration areas. Fire Safety 2019-11-21 2020-01-10 N
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Health 2019-04-17 2019-05-02 Y
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Health 2018-09-27 2018-11-16 N
Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. Health 2018-09-27 2018-11-16 N
Ensure each resident receives an accurate assessment. Health 2018-09-27 2018-11-16 N
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Health 2018-09-27 2018-11-16 N
Provide and implement an infection prevention and control program. Health 2018-09-27 2018-11-16 N
Establish policies and procedures for medical documentation. Fire Safety 2018-10-01 2018-11-16 N
Establish roles under a Waiver declared by secretary. Fire Safety 2018-10-01 2018-11-16 N
Establish methods for sharing information. Fire Safety 2018-10-01 2018-11-16 N
Provide family notifications of emergency plan. Fire Safety 2018-10-01 2018-11-16 N
Conduct testing and exercise requirements. Fire Safety 2018-10-01 2018-11-16 N
Have horizontal exits used in accordance with safety requirements. Fire Safety 2018-10-01 2018-11-16 N
Have exits that are accessible at all times. Fire Safety 2018-10-01 2018-11-16 N
Install proper backup exit lighting. Fire Safety 2018-10-01 2018-11-16 N
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Fire Safety 2018-10-01 2018-11-16 N
To conduct inspection, testing and maintenance of fire doors by qualified individuals. Fire Safety 2018-10-01 2018-11-16 N
Reasonably accommodate the needs and preferences of each resident. Health 2017-12-01 2018-01-20 N
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. Health 2017-12-01 2018-01-20 N
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. Health 2017-12-01 2018-01-20 N
Develop and implement policies and procedures to prevent abuse, neglect, and theft. Health 2017-12-01 2018-01-20 N
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2017-12-01 2018-01-20 N
Respond appropriately to all alleged violations. Health 2017-12-01 2018-01-20 N
Ensure each resident receives an accurate assessment. Health 2017-12-01 2018-01-20 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2017-12-01 2018-01-20 N
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Health 2017-12-01 2018-01-20 N
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Health 2017-12-01 2018-01-20 N
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Health 2017-12-01 2018-01-20 N
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Health 2017-12-01 2018-01-20 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2017-12-01 2018-01-20 N
Conduct risk assessment and an All-Hazards approach. Fire Safety 2017-11-30 2018-01-20 N
Address subsistence needs for staff and patients. Fire Safety 2017-11-30 2018-01-20 N
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. Fire Safety 2017-11-30 2018-01-20 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2017-11-30 2018-01-20 N
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Fire Safety 2017-11-30 2018-01-20 N
Have power receptacles that are properly grounded. Fire Safety 2017-11-30 2018-01-20 N
Have proper medical gas storage and administration areas. Fire Safety 2017-11-30 2018-01-20 N
Establish policies and procedures for sheltering. Fire Safety 2017-11-30 2017-12-15 N